Endovascular treatments of atherosclerotic renovascular disease: a narrative review and literature search.

In recent years, endovascular treatments have become more common in patients with renal artery stenosis and aneurysm. Although the treatment algorithms are not universally accepted, endovascular therapy can be readily utilized for the appropriate indications in the context of surgical treatment for renovascular diseases. The most important factor to consider is that the correct indication is applied for such treatment. Although the applied procedures are believed to have minimal risk, any complications that occur may result in major problems. Moreover, the pathology that is being treated (e.g., hypertension, high serum creatinine concentration, or low glomerular filtration rate) must be well defined. As stent and balloon technologies continue to be developed, more positive results are expected in the coming years. In the present study, we reviewed the endovascular treatment algorithms for atherosclerotic renovascular disease and performed a narrative review of the current literature.

Short-Term Results of Ivabradine versus Metoprolol: The Effects on Atrial Fibrillation in Patients Undergoing Off-Pump Coronary Artery Bypass Grafting.

INTRODUCTION: Classic coronary artery bypass grafting (CABG) surgery involves diastolic cardiac arrest under cardiopulmonary bypass, while off-pump CABG (OPCABG) has become widespread in recent years. METHODS: 174 patients who underwent OPCABG were included in the study. Patients were divided into two groups. Group I (n=90) received ivabradine and Group M (n=84) received metoprolol before surgery until postoperative day 10. Intraoperative arrhythmias and hypotension were recorded. Postoperative atrial fibrillation (AF) and arrhythmia, mortality and morbidity rates were assessed based on the 30-day postoperative follow-up. RESULTS: There were no significant differences in the intraoperative amount of inotropic support and red blood cell transfusion between groups (P=0.87 and P=0.31). However, the rates of intraoperative arrhythmias and hypotension were not significantly higher in Group M (P=0.317 and P=0.47). Ventricular tachycardia/ventricular fibrillation (VT/VF) was observed in 2 patients in both groups. Postoperative AF occurred in 7 patients (7.7%) in Group I and in 10 patients (11.9%) in Group M. Although there was a trend towards a higher prevalence of AF in Group M patients, this did not reach statistical significance. In addition, mortality and morbidity rates were comparable between groups.

The effectiveness of vacuum-assisted closure therapy in patients with infected venous leg ulcers.

AIM: In this study, we aimed to investigate the effect of vacuum-assisted closure therapy on venous stasis wound healing in patients with chronic venous leg ulcers. METHODS: Vacuum-assisted closure therapy was applied on a total of 14 venous leg ulcers. All patients had post-thrombotic syndrome. Quantitative wound culture samples were obtained before the procedure and local wound assessments were performed. The primary outcome measures included wound healing as assessed by a local wound examination during each dressing change and the rate and velocity of ulcer reduction. Wound healing was defined as the complete closure of the ulcer, while rapid wound healing was defined as a ≥ 30% reduction in the ulcer size by week four. RESULTS: No surgical debridement or surgical corrective procedure was applied in any patient. The mean length of hospital stay was 32.3 days. The mean number of vacuum-assisted closure therapies for each case was 17.8 and the mean time to dressing change was 72.3 hours. Multidrug-resistant Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus were detected in three and four patients, respectively. Wound culture results became negative after a mean duration of vacuum-assisted closure therapy of 12.1 days. None of the patients needed antibiotic therapy until the procedure was completed. Compared to baseline, the mean ulcer reduction rates were 46.4% for the first six applications and 72.8% for the subsequent applications. CONCLUSIONS: Our study results suggest that vacuum-assisted closure therapy promotes rapid wound healing in patients with severe post-thrombotic syndrome with venous stasis leg ulcers, and reduces the need for antibiotics by reducing the biological burden.

SYNTAX and Coronary Artery Calcium Score Predict Atherosclerotic Plaque Formation in the Ascending Aorta.

BACKGROUND: There is no study about the relationship between the complexity of coronary artery disease (SYNTAX SCORE; SS), and coronary artery calcium (CAC) score, accompanied with aortic calcium score (ACS) levels. The objective of this study was to investigate the relationship between the preoperative SS and CAC scores accompanying ACS in isolated CABG patients and their postoperative clinical results. METHODS: This study included 130 consecutive CABG patients. The mean age of the patients was 62.3 ± 8.62 years (range: 47-84 years). SS was measured using coronary angiography by an experienced cardiologist. We investigated the ACS accompanied with CAC scores using a multidetector computed tomography (MDCT) in the same session, preoperatively. Measurements of the CAC score and ACS were measured by an experienced radiologist, who was unaware of the study in the same session. In order to investigate aortic wall pathology in patients with positive aortic calcification, we provided aortic tissue samples prior to the proximal anastomosis of bypass grafts using No:11 scalpel. RESULTS: Overall median SS was 39 ± 7.2 (range: 15-41). CAC score was zero in 34 patients (26.1%). For the patients with a CAC score of zero, the median SS was 32 ± 9.4. There was no evidence of aortic calcification or plaque formation in 62 patients (47.6%). In these patients, the median SS was 35.6 ± 11.3. No significant difference was found when both groups were compared and for those patients with a calcific score of zero (P = .85). The median CAC score and ACS were 238 ± 122 AU (range: 0-1238 AU) and 112 ± 40 AU (range: 0-730 AU), respectively (P = .0033). For patients with a CAC score and ACS ≥400 AU, the mean SYNTAX score was ≥ 37. SS was correlated with CAC score (R:0.585; P < .0001). SYNTAX was correlated with ACS (R:0.557; P < .001). In multivariate analysis of SS (OR 1.053, 95% CI: 1.003-1.106, P = .039), gender (OR 0.189, 95% CI: 0.053-0.678, P = 0.011), age (OR 1.454, 95% CI: 1.256-1.632, P = .012), and diabetes mellitus (OR 0.341, 95% CI: 1.006-1.124, P = .014) were independent predictors for CAC score and aortic calcification. CONCLUSIONS: CAC score and ACS are strongly correlated with the complexity of coronary arteries in CABG patients. The total CAC score (≥ 400 AU) was independently associated with the degree of SS (>37). To prevent MACCE and mortality in CABG patients, we suggest the measurement of CAC score accompanied with ACS using MDCT as a non-invasive method. Highlight points: • Atherosclerotic plaque formation in aorta and coronary arteries are the main risk factors for stroke and infarction in CABG operations. •SYNTAX score value and aortic atherosclerosis levels are directly correlated. •SYNTAX score may predict the complications due to atherosclerosis during heart surgery.

Incidence of atrial fibrillation and its effects on long-term follow-up outcomes in patients undergoing primary percutaneous coronary intervention for ST-elevation myocardial infarction.

OBJECTIVE: The incidence of atrial fibrillation (AF) in patients with ST segment elevation myocardial infarction (STEMI) varies between 7% and 21%, and most of these studies were in the thrombolytic era. However, the frequency of new-onset AF during the primary percutaneous coronary intervention (PCI) period is still unclear. We aimed to investigate the frequency of new-onset AF and its effects on long-term clinical events in patients undergoing primary PCI. METHODS: A total of 1,603 patients who were diagnosed with STEMI and underwent primary PCI were included in the study. All the patients were monitored for at least 48 hours after the procedure. The primary endpoint of the study was defined as new-onset AF during hospitalization. RESULTS: The median follow-up period of our study was 44 months. New-onset AF developed in 85 (6.1%) patients. CHADs-VASc > 2, KILLIP > 2, and left atrial diameter were found to be independent predictors for the development of new-onset AF. In the AF (+) group, the all-cause and in-hospital mortality rates were found to be significantly higher. New-onset AF development in patients with STEMI was detected as an independent predictor of in-hospital mortality. CONCLUSION: In the era of primary percutaneous transluminal coronary angioplasty, new-onset AF rates were found to be lower than the literature data. In addition, new-onset AF was found to be a predictor of in-hospital mortality, and deaths occurred mostly in the early period. Therefore, close follow-up of these patients in the early period and re-evaluation in terms of AF burden when the patient becomes stable are important.

Comparison of Demographic Profile, Laboratory, Epidemiology and Clinical Outcomes in Patients with Native Valve and Prosthetic Valve Endocarditis.

BACKGROUND: Infective endocarditis (IE) is a heterogenous infection that affects the endothelial surface of the intracardiac structures and other implanted intracardiac devices. We aimed to compare demographical characteristics, causative microorganisms, treatment, and prognosis of prosthetic and native valve endocarditis diagnosed in two separate hospitals. MATERIAL AND METHODS: Between 2010 and 2020, patients admitted with the diagnosis of IE were retrospectively included in our multicenter study. Patients' demographic and epidemiological data, clinical characteristics, infected intracardiac structure and sort of valve, culprit microorganisms, laboratory findings, treatment manifestations and in-hospital outcomes with a period of 6 months were obtained from an electronic medical record system. RESULTS: A total of 173 consecutive patients had diagnosed IE, 60.1% (104 patients) of them native valve endocarditis (NVE) and 39.8 % (69 patients) of them prosthetic valve endocarditis (PVE).  Baseline demographic properties were not different except hypertension and atrial fibrillation. Patients with prior hypertension were 25% (26 patients) in NVE; 39.1% (27 patients) in PVE and the difference was statistically significant. Septic shock was significantly higher in the PVE group than the NVE group (7.4% versus 1%; P = .036), and also recurrent endocarditis occurred more frequently in the PVE group than the NVE group (8.8% versus 1%; P = .016). CONCLUSION: In our study, although we detected higher mean age, HT, RDW and atrial fibrillation rates compared with NVE, we did not detect a significant difference in mortality and morbidity.

Is it possible to predict atherosclerosis in the ascending aorta by the patient's lipid panel?

INTRODUCTION: Atherosclerosis is a chronic inflammatory event characterized by stiffness and thickening of the vascular walls. In our daily practice, we assume the atherosclerotic potential of the patient by following the total cholesterol, high-density lipoprotein (HDL), low-density lipoprotein (LDL) and triglyceride levels (lipid panel). We aimed to understand the relation between the HDL, LDL, cholesterol levels and the atherosclerosis in large vascular structures such as the ascending aorta. MATERIAL AND METHODS: We have searched for atherosclerosis in the aortic tissue samples from 48 patients. It is a study in which we examine the correlation of preoperative cholesterol values (HDL, LDL, triglyceride, total cholesterol) by dividing the patients into two groups according to the presence of plaque. RESULTS: Forty-three (89.6%) male and 5 (10.4%) female patients between 39 and 81 years of age were included in the study. There was no statistically significant difference between the patients' preoperative cardiovascular risk assessments. The free T3 values were within the normal range in all patients, but there was a difference that patients in the non-atherosclerosis group had lower values. There was no statistically significant difference between the two groups' HDL, LDL, total cholesterol, or triglyceride parameters. CONCLUSIONS: As a result, in our study, no significant difference was found between HDL-C, LDL-C, triglyceride, total cholesterol values and the pathological process of aortic atherosclerosis. As a result of this study, we believe that it was necessary to correct the error margins of these parameters. In addition, it required the need for a clearer laboratory parameter to demonstrate atherosclerosis.

Is malignancy associated with pericardial effusion fluid volume or fluid character?

INTRODUCTION: Pericardial effusion develops due to different etiologies. The main goals of our study are to understand the etiology and determine whether the amount of pericardial effusion is significant in terms of malignancy. MATERIAL AND METHODS: 142 patients with pericardial effusion, who met the criteria between 1 January 2014 and 1 January 2019, were retrospectively analyzed. All of these patients underwent operation with the subxiphoidal approach. The fluid samples were sent to the microbiology and pathology laboratories for evaluation. Patients underwent follow-up after 1 month. RESULTS: Of the patients included in this study, 72 (61%) of 118 patients were operated on under general anesthesia with a laryngeal mask, and 46 (39%) underwent sedation and local anesthesia. The etiologies found in patients were as follows: effusions resulting from malignancy in 27 (22.9%), idiopathic in 24 (20.3%), cardiac causes (depending on the use of anticoagulants or postoperation) in 22 (18.6%), uremia in 20 (16.9%), infection in 18 (15.3%), and heart failure in 7 patients. The amount of fluid drained from the patients was 661.61 ± 458.34 mL. Out of 27 patients with malignancy, 21 (77.8%) had drainage over 500 mL of effusion fluid, and 6 (22.2%) had drainage under 500 mL. Patients who had positive results tended to have drainage over 500 mL compared with patients who had negative results in terms of malignancy (P = .033). CONCLUSION: The subxiphoidal approach to pericardial effusion is an easily applicable operation, whether therapeutic or diagnostic. The advantages of the subxiphoidal approach include drainage of all of the fluid and ease of sampling the pericardial fluid. We believe that the amount of fluid drained can lead us to consider malignancy as an etiology.

Comparison of Short and Mid-Term Mortality and Morbidity in Patients With Severe Aortic Stenosis (Intermediate/High Risk) Who Underwent Transcatheter Aortic Valve Replacement and Surgical Aortic Valve Replacement.

Treatment protocols for severe aortic valve stenosis include surgical aortic valve replacement (SAVR), balloon valvuloplasty, transcatheter aortic valve replacement (TAVR), and medical  treatment. Because the success rates are getting higher with both SAVR and TAVR, making the right treatment decision is important. This study retrospectively shows the short- (1 month) and mid-term (6 months) mortality and morbidity rate differences between 2 groups of patients, who arrived to our hospital from January 2014 through October 2018. The first group consists of 54 patients who underwent mid-high risk SAVR operations at Istanbul University-Cerrahpasa, Institute of Cardiology, Department of Cardiovascular Surgery. The second group consists of 57 patients who underwent TAVR at the Cardiology Department. Preoperative evaluation showed that the mean age of the SAVR group (71.5 years) was higher than the TAVR group (80 years). Also, the history of previous cardiac valve replacement surgery significantly was higher in the SAVR group than the TAVR group (P = .028). There were no significant differences between the remaining preoperative tests and diagnostic procedures. Of the patients who underwent SAVR, 3.7% experienced postoperative cardiac arrhythmias, while the 17.5% of patients from the TAVR group experienced cardiac arrhythmias after the procedure. This difference between the groups were statistically significant. Mortality rate was 9.3% in the SAVR group and 5.3% in the TAVR group. The mortality rate was not statistically different between the groups. There was no significant difference between the groups in the means of neurological incidents. The TAVR group had more vascular complications (17.9% to none) and pacemaker implantations (21.4% to 1.9%). Minor or major bleeding was the most common reason for admission to the hospital after SAVR. Seven out of 10 patients experienced bleeding. Aortic regurgitation was more common in the TAVR group at the first and sixth month following the procedure. Ratios between the gradient values were higher in the SAVR group (P < .001). Peak gradient values at the sixth month following the procedure were lower than the values of the first month (P < .040). Aortic regurgitation symptoms increased with patients at the mid-term follow-up appointment. To prevent the vascular complications in the TAVR group, preoperative peripheral vascular examination thoroughly should be performed. Considering that bleeding disorders are the main reason the SAVR group arrived to the hospital, INR values should closely be monitored. There seems to be no mortality difference between the groups at the six-month follow up, but studies should continue with more patients and long-term results.

Prediction of Protein Metal Binding Sites Using Deep Neural Networks.

Metals have crucial roles for many physiological, pathological and diagnostic processes. Metal binding proteins or metalloproteins are important for metabolism functions. The proteins that reach the three-dimensional structure by folding show which vital function is fulfilled. The prediction of metal-binding in proteins will be considered as a step-in function assignment for new proteins, which helps to obtain functional proteins in genomic studies, is critical to protein function annotation and drug discovery. Computational predictions made by using machine learning methods from the data obtained from amino acid sequences are widely used in the protein metal-binding and various bioinformatics fields. In this work, we present three different deep learning architectures for prediction of metal-binding of Histidines (HIS) and Cysteines (CYS) amino acids. These architectures are as follows: 2D Convolutional Neural Network, Long-Short Term Memory and Recurrent Neural Network. Their comparison is carried out on the three different sets of attributes derived from a public dataset of protein sequences. These three sets of features extracted from the protein sequence were obtained using the PAM scoring matrix, protein composition server, and binary representation methods. The results show that a better performance for prediction of protein metal- binding sites is obtained through Convolutional Neural Network architecture.

Presence of Aggregatibacter actinomycetemcomitans in saliva and cardiac tissue samples of children with congenital heart disease.

AIM: The purpose of this study was to analyze the presence of Aggregatibacter actinomycetemcomitans in saliva and cardiac tissue samples of children requiring cardiac surgery in Istanbul, Turkey. SUBJECTS AND METHODS: Twenty-five patients (mean age: 6.24 ± 2.93) undergoing surgery for congenital heart defects (CHDs) and an age/gender-matched control group of 25 healthy children were enrolled in the study. Saliva samples were collected from all children; plaque index (PI) and gingival index (GI) were also determined. In CHD group, cardiac tissue samples were received during surgery. All samples were evaluated for the presence of A. actinomycetemcomitans and its highly leukotoxic JP2 clonal strains using polymerase chain reaction. The findings were analyzed by Mann-Whitney U, Chi-square, and Fisher's exact tests. RESULTS: No significant differences were found in PI and GI values between the groups. A. actinomycetemcomitans was not detected in cardiac tissue samples. A. actinomycetemcomitans in saliva was detected in 2 (8%) of the CHD and 5 (20%) of the control children (p > 0.05). A. actinomycetemcomitans JP2 clonal strains were determined from 1 (4%) of the control group while it was not determined from the samples of the CHD group. CONCLUSIONS: Early colonization of A. actinomycetemcomitans in oral cavities could be assessed as a risk marker for periodontal disease. Periodontal pathogens may enter bloodstream through bacteremia; thus, the presence of periodontal pathogens in the oral cavity of children should be assessed as a risk marker for cardiac diseases in older ages.

Coronary flow reserve in patients with left anterior descending artery-left internal mammary artery long patch plasty anastomosis: a prospective study.

BACKGROUND: We aimed at assessing the efficacy of the patch plasty technique without endarterectomy in patients with diffuse coronary artery. Long anastomosis of the left internal mammary artery graft (LIMA) to the left anterior descending (LAD) artery was performed and examined using transthoracic Doppler echocardiography to detect coronary flow reserve (CFR) and epicardial stenosis. METHODS: Forty-one patients (6 women; mean age, 58 ± 9 years) who underwent coronary artery bypass surgery using the patch plasty technique without endarterectomy were included in the study. Presence of CFR was examined in each patient by transthoracic Doppler echocardiography. RESULTS: One of the patients (2.4%) died on the first postoperative day. The remaining patients were divided into 2 groups: those with normal CFR (CFR ≥ 2) (n = 35, 88%) and those with low CFR (CFR < 2) (n = 5, 12.0%). The length of patch plasty (3.6 ± 0.82 cm) in the low CFR group was significantly longer than that in the normal CFR group (2.69 ± 0.75 cm). Coronary angiography was performed for the 3 patients with CFR < 2: Two patients showed normal grafts and anastomoses, but the third patient's distal LAD-LIMA anastomosis was almost 90% occluded. CONCLUSION: We elucidated the reliability of the patch plasty without endarterectomy method and transthoracic Doppler echocardiography for detecting the severity of coronary artery disease.

Coronary artery bypass graft surgery in a patient with ureterosigmoidostomy.

A 75-year-old male patient had stable angina pectoris. After coronary angiography we decided to perform a coronary artery bypass graft surgery. Twenty years ago the patient underwent radical cystectomy and bilateral ureterosigmoidostomy because of bladder cancer. After that, his micturition was via the rectum. We did not experience that before. As is known, monitoring of urine output is very important after cardiac surgery. The patient was consulted with an urologist for how to monitor urine output in him. Transrectal catheterization was recommended for our follow-up, but before the catheterization bowel cleansing is necessary. Four-vessel on-pump coronary artery bypass graft surgery was performed without any problem. Peroperative urine volume and arterial blood gas results were normal. Urine output is a sensitive variable reflecting the patient's effective blood volume and tissue perfusion. Urinary catheterization is a standard for all cardiac surgeries, and it allows the patients' urine to drain freely from the bladder for collection. Monitoring of urine output in patients with ureterosigmoidostomy is impossible by standard urinary catheterization method. In this case we performed transrectal catheterization for Urine flow follow-up. Urine flow follow-up is essential after the open-heart surgery and it can be measured in different ways, as in our case.

Does pulmonary artery venting decrease the incidence of postoperative atrial fibrillation after conventional aortocoronary bypass surgery?

OBJECTIVES: In this study, we tested the hypothesis that pulmonary artery venting would decrease the incidence of atrial fibrillation after coronary artery bypass surgery. METHODS: This prospective study included 301 patients who underwent complete myocardial revascularization with cardiopulmonary bypass in our department during a 2-year period. The patients were randomly divided into 2 groups: group I included 151 patients who underwent aortic root venting and group II included 150 patients who underwent pulmonary arterial venting for decompression of the left heart. Pre-, peri-, and postoperative risk factors for atrial fibrillation were assessed in both groups. RESULTS: The mean age was similar in the 2 groups. The mean number of anastomoses was significantly higher in group I (2.8 ± 0.8) than in group II (2.4 ± 0.8) (P = 0.001). The mean cross-clamp time was 42.7 ± 17.4 minutes in group I and 54.1 ± 23.8 minutes in group II (P = 0.001). The mean cardiopulmonary bypass time was 66.4 ± 46.1 minutes in group I and 77.4 ± 28.6 minutes in group II (P = 0.08). The incidence of atrial fibrillation was 14.5% (n = 21) in group I and 6.5% (n = 10) in group II (P = 0.02). Multivariate regression analysis showed that pulmonary artery venting decreased the postoperative incidence of atrial fibrillation by 17.6%. CONCLUSIONS: Pulmonary arterial venting may be used as an alternative to aortic root venting during on-pump coronary bypass surgery, especially in patients at high risk of postoperative atrial fibrillation.

Combined transdiaphragmatic off-pump and minimally invasive coronary artery bypass with right gastroepiploic artery and abdominal aortic aneurysm repair.

PATIENT: Male, 74 FINAL DIAGNOSIS: Abdominal aortic aneurysm (AAA) Symptoms: Palpable abdominal mass Medication: - Clinical Procedure: Abdominal aortic aneurysm repair Specialty: Surgery. OBJECTIVE: Rare disease. BACKGROUND: Coronary artery disease is common in elderly patients with abdominal aortic aneurysms. Here we report a case of the combination of surgical repair for abdominal aortic aneurysm and off-pump and minimally invasive coronary artery bypass surgery. CASE REPORT: A 74-year-old man who presented at our clinic with chest pain was diagnosed with an abdominal aortic aneurysm. His medical history included right coronary artery stenting. Physical examination revealed a pulsatile abdominal mass on the left side and palpable peripheral pulses. Computed tomography scans showed an infrarenal abdominal aneurysm with a 61-mm enlargement. Coronary angiography revealed 80% stenosis in the stent within the right coronary artery and 20% stenosis in the left main coronary artery. The patient underwent elective coronary artery bypass grafting and abdominal aortic aneurysm repair. Abdominal aortic aneurysm repair and transdiaphragmatic off-pump and minimal invasive coronary artery bypass grafting with right gastroepiploic artery were performed simultaneously in a single surgery. CONCLUSIONS: We report this case to emphasize the safety and effectiveness of transdiaphragmatic off-pump and minimally invasive coronary artery bypass surgery with abdominal aortic aneurysm repair. This combined approach shortens hospital stay and decreases cost.

Prevalence of salivary Streptococcus mutans serotype k in children undergoing congenital heart surgery.

OBJECTIVE: The prevalence of Streptococcus mutans serotype k, which was speculated that might be associated with the development of cardiovascular diseases, has been reported in adult cardiovascular surgery patients. There is no information about presence of serotype k in children with cardiac disease. The aim of this study was to determine the salivary prevalence of S. mutans serotype k in children with congenital heart disease. STUDY DESIGN: Salivary samples of 25 patients undergoing elective surgery for congenital heart defects with cardiopulmonary bypass and an age and gender matched control group of 25 healthy children were enrolled in the study. Species-specific 16SrRNA gene sequences were used for S. mutans and serotype-specific rgpF gene sequences were used for S. mutans serotype k determination in stimulated saliva samples. RESULTS: S. mutans was detected in 19 (76%) of the study and 15 (60%) of the control children. The difference was not shown to be statistically significant. Serotype k was determined from 3 (12%) of the study group, while it was not determined from the samples of the control group. CONCLUSIONS: Our results indicate that those children with congenital heart disease may possess S. mutans serotype k in oral cavity at a higher frequency as similar with the adult cardiac surgery patients.